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�. SAN JOAQUIN LOCAL HEALTH DISTRICT Id <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466 -6781 �r � i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued JAN ] $ 1978 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION _J�=(� 70 n -CENSUS TRACT <br /> Owner's Name �� � ,� � Phone <br /> 1 r n ,� I <br /> Address - ..1.—C'�� 7 P�,1 AQ 7 e),, 1�-c�l City - <br /> Contractor's NametiLicense #2 q Phone q_3 3 <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /-T <br /> Other .� — <br /> DISTANCE TO NEAREST: " SEPTIC TANK /,jL SEWER_ LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL __ Q <br /> INTENDED USE TYPE OF,WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Qt <br /> X Domestic/private ' Drilled Dia. of Well Casing q <br /> Domestic/public Driven y`_, Gauge of Casing F <br /> Irrigation Gravel Pack , ; Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: fio a/I t Q <br /> PUMP INSTALLATION: Contractor <br /> s Type of Pump H.P. <br /> 'r <br /> PUMP REPLACEMENT: / / S tate� Work Done <br /> PUMP .REPAIR: / /,` ,State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> ` Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or -regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local. Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND.A FINAL INSPECTION. ! <br /> SIGNEDMZ-AP, _ TITLE <br /> (DRAW PLOT PLAN 'ON REVERSE SIDE) " <br /> FOR DEPARTMENT USE ONLY Tj <br /> PHASE I <br /> APPLICATION ACCEPTED BY �^ DATE F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � � DATE INSPECTION BY DATE )_/9(____J. � <br /> 2M <br />